diabetes mellitus & perioperative anaesthetic management

DIABETES MELLITUS & PERIOPERATIVE MANAGEMENT

SPEAKER DR. TUHIN MISTRY

MODERATORPROF. VANDANA MANGAL

PART - I

INTRODUCTION

Diabetes mellitus is a metabolic disorder with an increasing global

incidence and prevalence.

With an increasing incidence worldwide, DM will be likely a leading

cause of morbidity and mortality in the future.

Poor peri-operative glycaemic control increases the risk of adverse

outcomes.

INTRODUCTION(CONTD…)

The effects of surgical stress and anesthesia have unique effects

on blood glucose levels, which should be taken into consideration

to maintain optimum glycemic control.

Interestingly, the literature still does not report a consensus

perioperative glucose management strategy for diabetic patients.

Overall, through careful glycemic management in perioperative

period, we may reduce morbidity and mortality and improve

surgical outcomes.

“A metabolic disorder of multiple aetiology

characterized by chronic hyperglycaemia with

disturbances of carbohydrate, fat and protein

metabolism resulting from defects in insulin secretion,

insulin action, or both”

- WHO

CLASSIFICATION

Type 1 diabetes

Type 2 diabetes

Gestational diabetes mellitus (GDM)

Specific types of diabetes due to other causes

1. Monogenic diabetes syndromes

2. Diseases of the exocrine pancreas

3. Drug- or chemical-induced diabetes

- American Diabetes Association. Diabetes Care. 2015; 38(suppl 1): S8-S16

EPIDEMIOLOGY

India is the “Diabetes Capital of the World”

About 77 million are considered to be pre-diabetic.

Over 60 million diagnosed with diabetes.

Projected to at least double by 2030.

Smoking, poor physical activity and alcohol use are some

pertinent risk factors of diabetes in India.

- http://globalhealthaging.org(24/07/2015)

PATHOGENESIS

TYPE I TYPE II

SYMPTOMS AND SIGNS

TYPE I TYPE II

SCREENING AND DIAGNOSIS OF

DIABETES

MANAGEMENT OF DIABETES

MEDICAL NUTRITION THERAPY (MNT)

- American Diabetes Association. Diabetes Care. 2015; 38(suppl 1): S8-S16

The daily requirement :

• 1.5-2.5 litres of water

• 50-100 mmol of sodium,

• 40-80 mmol of potassium,

• 180g glucose is needed to prevent catabolism.

• may require magnesium, phosphate…..

INSULIN PREPARATIONS

- Harrison's Principles of Internal Medicine, 19th Edition

REPRESENTATIVE INSULIN REGIMENS


AGENTS USED FOR THE TREATMENT OF TYPE 1 OR TYPE 2 DIABETES

MEDICAL CARE FOR DIABETES PATIENTS

Optimal and individualized glycemic control

Self-monitoring of blood glucose(individualized frequency)

HbA1c testing (2-4 times/year)

Patient education in diabetes management (annual)

Medical nutrition therapy


Blood pressure measurement (quarterly)(Target <140/90)

Management of dyslipidemia: screening at diagnosis, 1-2 years

thereafter

Consider antiplatelet therapy: 75-162 mg/day( in increased

CVD risk)

Screening for diabetic nephropathy (annual urine albumine)

Eye examination (annual or biannual)


Foot examination (1 -2 times/year by physician; daily by

patient).

Neuropathy screening.

Immunizations:

COMPLICATions of diabetes

HYPOGLYCEMIA

Blood sugar level <70 mg/dl(ADA 2015)

Signs & symptoms:

Treatment:

1. Oral glucose(15-20 gms, repeat after 15 mins)

2. IV 50%D 25-50 ml or as much as possible until patient’s mental state

recovers.

3. If hypoglycemia is caused by long acting insulin continue 10%

dextrose drip for 24 - 48 hrs.

4. Glucagon 1 mg IM , SC can be given to treat severe hypoglycemia, if

IV access is difficult.

DKA & NKHHSDKA NKHHS

GLUCOSE 200 – 500 600 – 2400

SODIUM 125 -135 meq/l 140 -150 meq/l

PottasiumNORMAL TO

INCREASEDNORMAL

PHOSPHATE DECREASED NORMAL

OSMOLALITY 300 – 320 330 – 380

FLUID DEFICIT 4 – 6 LITRES 7 – 10 LITRES

pH <7.3 >7.3

Pco2 Decreased Normal

Anion gap Increased Normal

Ketones ++++ +/-

Insulin requirement more less

Mortality <5% >50 to 60 %


IMPACT OF SURGERY ON DIABETES

Metabolic effects of starvation:

Period of starvation induces a catabolic state.

It will stimulate secretion of counter-regulatory hormones.

Metabolic effects of major surgery:

counter- regulatory hormones (epinephrine, glucagon, cortisol and

growth hormone)

inflammatory cytokines IL-6 and tumor necrosis factor-alpha.

Hypoglycemia: Exacerbate the catabolic effect of surgery

Neuro-hormonal changes result in

Increased insulin resistance.

Decreased peripheral glucose utilization.

Impaired insulin secretion.

Increased lipolysis .

Protein catabolism, leading to

HYPERGLYCEMIA and even KETOSIS in some cases…

REASONS FOR ADVERSE OUTCOME

Hypo and hyperglycemia.

Multiple co-morbidities microvascular and macrovascularcomplications.

Inappropriate use of intravenous insulin infusion.

Management errors when tailoring from the intravenous insulininfusion to usual medication.

Lack of institutional guidelines.

Peri-operative infection.

GENERAL PRINCIPLES

Diabetes should be well controlled prior to elective surgery.

Avoid insulin deficiency and anticipate increased insulin

requirements.

The patient’s diabetes care provider should be involved in the

management of their patient’s diabetes peri-operatively.

Patients must be given clear written instructions concerning the

management of their diabetes both pre- and post-operatively

(including medication adjustments) prior to surgery.

CONTD…

Patients must not drive themselves to the hospital on the day of

the procedure(Day Care Surgery).

Patients with diabetes should be on the morning list, preferably

first on the list.

Patients should be well hydrated before the procedure.

These guidelines may need to be individually modified

depending on the patient’s circumstance.

PRE-OPERATIVE EVALUATION

GOALS Establishment of certain glycemic target levels, <180 mg/dL in critical

patients and < 140 mg/dL in stable patients. *

Avoidance of severe hyperglycemia or hypoglycemia.

Prevention of ketoacidosis.

Maintenance of physiological electrolyte and fluid balance.

Reduction of overall patient morbidity and mortality.

* Sivakumar Sudhakaran and Salim R. Surani, “Guidelines for Perioperative Management of the

Diabetic Patient,” Surgery Research and Practice, vol. 2015

PRE-0PERATIVE EVALUATION

To Assess History/Examination Investigation

1. Blood Sugar Control

Hypo/Hyperglycemic

episodes,

Hospitalization

BS- F & PP

HbA1C

2. Nephropathy

H/O- HTN, Swelling over body,

Recurrent

UTI.

Urine R/E and M/E

RFT

3. Cardiac Status

H/O- Angina/ MI , Swelling of

feet,

Exercise intolerance

ECG, CXR, ECHO,TMT

4. PVD

H/O- Intermittent Claudication,

Blanching of feet,

Non healing ulcer

USG doppler

CONTD..

To Assess History/Examination Investigation

5. Retinopathy H/O - Visual disturbances Fundus Examination

6. ANS

Early satiety, abdominal distension,

Anhidrosis, Impotence, Orthostatic

Syncope

Postural change in BP, HR

variability with exercise,

tachycardia response to

atropine

7. Metabolic &

Electrolyte

H/O- Starvation, Infection

Sign of DKA,

ABG, Urinary Ketone,

Sr. Electrolyte

8. Airway

Scleredema diabeticorum,

Stiff Joint Syndrome

(Prayer sign, Palm Print test)

X-ray cervical spine

AP & Lateral

Prayer Sign

Palm Print Test

Modified Mallampati Grade

Head Extension

In diabetics palm print is the best single predictor of

a difficult intubation, followed by Mallampati and the

prayer sign.*

*Hashim K, Thomas M. Sensitivity of palm print sign in prediction of

difficult laryngoscopy in diabetes: A comparison with other airway

indices. Indian Journal of Anaesthesia. 2014;58(3):298-302.

doi:10.4103/0019-5049.135042.

CLINICAL SYMPTOMS & SIGNS OF DAN

CARDIOVASCULAR:

Resting Tachycardia

Exercise intolerance

Orthostatic hypotension

Painless MI

GI:

Esophageal dysmotility

Gastroparesis

Constipation

Diarrhoea

Fecal incontinence

CLINICAL SYMPTOMS & SIGNS OF DAN(CONTD…)

GENITOURINARY:

Neurogenic bladder

Erectile dysfunction

Retrograde ejaculation

Female sexual dysfunction

METABOLIC:

Hypoglycemic unawareness

Hypoglysemia associated autonomic failure

CLINICAL SYMPTOMS & SIGNS OF DAN(CONTD…)

SUDOMOTOR:

Anhydrosis

Heat intolerance

Gustatory sweating

Dry skin

PUPILLARY:

Functional impairement

ARP

TESTS FOR DIABETIC AUTONOMIC NEUROPATHY

Early stage: abnormality of HR response during deep breathing

Intermediate stage: abnormality of Valsalva response

Late stage: presence of postural hypotension

The test are valid marker of DAN if following factors ruled out.

1. End organ failure

2. Concomitant illness

3. Drugs: antidepressents, antihistamines, diuretics, vasodilators, sympathatic

blockers, vagolytics.

TEST FOR AUTONOMIC NEUROPATHY(CONTD…)

Heart rate variability (HRV) in response to:

Deep breathing

Standing

Valsalva maneuver

BP response to:

1. Standing or passive tilting

2. Sustained hand grip

3. Valsalva maneuver

TEST FOR PARASYMPATHETIC CONTROL

Heart rate variability (HRV) in response to:

Deep breathing:

Respiratory sinus arrhythmia is a normal phenomenon due to

vagal input to sinus node during expiration causing cardio deceleration.

The patient lies quietly and breathes deeply at a rate of 6

breaths/min (a rate that produces maximum variation in heart rate) while a

heart monitor records the difference between the maximum and minimum

heart rates.

Normal variability: >15 beats/min

Abnormal variability: <10 beats/min

TESTS(CONTD…)

Standing:

This test evaluates the cardiovascular response elicited by a change from a

horizontal to a vertical position.

In healthy subjects,

Standing rapid increase in heart rate that is maximal at approximately

the 15th beat relative bradycardia that is maximal at approximately the 30th

beat after standing.

The patient is connected to an ECG monitor while lying down and then

stands to a full upright position.

ECG tracings are used to determine the 30:15 ratio, calculated as the ratio

of the longest R-R interval (found at about beat 30) to the shortest R-R

interval (found at about beat 15).

The maximum and minimum R-R intervals may not always

occur at exactly the 15th or 30th beats after standing

Ziegler et al.* redefined the maximum/minimum 30:15 ratio as

the longest R-R interval during beats 20–40 divided by the

shortest R-R interval during beats 5–25.

In patients with diabetes and autonomic neuropathy, there is

only a gradual increase in heart rate(30:15 ratio):

>1.04 = normal

1.01-1.03 = borderline

< 1.01 = abnormal

* Ziegler D, Laux G, Dannehl K, Spuler M, et al.: Assessment of cardiovascular autonomic function: age-

related normal ranges and reproducibility of spectral analysis, vector analysis, and standard tests of heart

rate variation and blood pressure responses. Diabet Med. 1992; 9:166–175.

Valsalva maneuver:

supine patient, connected to an ECG monitor

forcibly exhales into the mouthpiece of a manometer, exerting a pressure of 40 mm

of Hg, for 15 seconds with an open glottis.

sudden transient increase in intra-thoracic and intra-abdominal pressures, with a

characteristic hemodynamic response.

The Valsalva Ratio is determined from the ECG tracings by calculating the ratio

of the longest R-R interval after the maneuver (reflecting the bradycardic

response to blood pressure overshoot) to the shortest R-R interval during or

shortly after the maneuver (reflecting tachycardia as a result of strain).

Ratio < 1.2 is abnormal

The response has four phases and in healthy individuals can be

observed as follows:

Phase I: Transient rise in BP and a fall in HR

Phase II: Early fall in BP with a subsequent recovery of BP later

in the phase, accompanied by an increase in HR.

Phase III: BP falls and heart rate increases with cessation of

expiration.

Phase IV: BP increases above the baseline value (overshoot)

TEST FOR SYMPATHETIC CONTROL

BP response to:

Standing or passive tilting:

Orthostatic hypotension is defined as a decrease in SBP of 20 mm Hg or a

decrease in DBP of 10 mm Hg within 3 minutes of standing when compared

with blood pressure from the sitting or supine position.

Alternatively, the diagnosis can be made by head-up tilt-table testing at an

angle of at least 60 degrees.

BP is rapidly corrected by baroreflex-mediated peripheral vasoconstriction

and tachycardia.

• A fall of more than 30 mm Hg is abnormal

• A fall of 10 to 29 mm Hg is borderline

Response to isometric exercise:

Sustained muscle contraction as measured by a handgrip dynamometer

causes a rise in systolic and diastolic blood pressure and heart rate.

The dynamometer is first squeezed to isometric maximum, then held at 30% of

maximum for 5 min.

This rise is caused by a reflex arc from the exercising muscles to central

command and back along efferent fibers. The efferent fibers innervate the

heart and muscle, resulting in increased CO, BP and HR.

DBP >16 mm of Hg = normal; <10 mm of Hg = abnormal

PRE-0PERATIVE GLYCEMIC CONTROL

Currently, there is no evidence-based guideline dictating when to cancel

surgery due to hyperglycemia.

Elective surgery should not be performed on patients in a compromised

metabolic state (DKA, HHS, etc.).

If serum glucose is >400 mg/dl (Yale New-Haven Hospital recommendation) or

>500 mg/dl (Boston Medical Center recommendation), the nonurgent surgical

procedures should be postponed and metabolic state restabilized.*

BGL should be kept between 5–10 mmol/L(90-180mg/dl) during the

perioperative period .

* Sivakumar Sudhakaran and Salim R. Surani, “Guidelines for Perioperative Management of the Diabetic Patient,” Surgery

Research and Practice, vol. 2015.

PRE-0PERATIVE GLYCEMIC CONTROL(CONTD…)

Postpone elective surgery if possible if glycaemic control is poor (HbA1c ≥

9%).

For critically ill patients who require admission to the intensive care unit

post-operatively, a “tighter” BGL target (e.g 4.4-6.1 mmol/L) may not

convey any greater benefit.

Hypoglycemia must be avoided.

All patients with diabetes treated with insulin should be managed in the

same way, irrespective of whether they have type 1 or type 2 diabetes

mellitus.

DRUGS TO BE DISCONTINUED

Insulin:

Long-acting insulin is discontinued 2-3 days prior to surgery

DRUGS TO BE DISCONTINUED

Biguanides:

Metformin sensitize specific tissues to insulin, mediating efficient uptake of

glucose in muscle and fat while preventing hepatic glucose formation.

Should be discontinued before surgery due to:

Intraop hemodynamic instability

decrease renal perfusion

risk of lactic acidosis. *

* C. J. Bailey and R. C. Turner, “Metformin,” The New England Journal of Medicine, vol. 334, no. 9, pp. 574–

579, 1996.

Thiazolidinediones:

Mechanism of action is similar to that of metformin.

Not associated with lactic acidosis.

Discontinued as they are not insulin secretagogues.

Increased cardiac events in patients on rosiglitazone.

May also cause fluid retention in the postoperative phase.*

* L. F. Meneghini, “Perioperative management of diabetes: translating evidence into practice,” Cleveland

Clinic Journal of Medicine, vol. 76, no. 4, pp. S53–S59, 2009.

Sulfonylureas:

trigger insulin production and may induce hypoglycemia in a fasting

preoperative patient.

K+ channel blocking effects may interfere with myocardial ischaemic

preconditioning increasing risk of cardiac complication.

If a patient has mistakenly taken a sulfonylurea on the day of surgery,

the operation may still be completed; however, careful glucose

monitoring is imperative and IV dextrose may be required.*

* L. C. Groop. Sulfonylureas in NIDDM, Diabetes Care, vol.15, no. 6, pp. 737–754, 1992.

Alpha glucosidase inhibitors:

weaken the effect of oligosaccharidases and

disaccharidases in the intestinal brush border, effectively

lowering the absorption of glucose after meals.

In preoperative fasting states, this drug has no effect and

thus should be discontinued until the patient resumes

eating.*

* M. Toeller. Alpha glucosidase inhibitors in diabetes: efficacy in NIDDM subjects. European

Journal of Clinical Investigation,vol. 24, supplement 3, pp. 31–35, 1994.

GLP-1 agonists:

Hold on the day of surgery

Decrease gastric motility. May delay restoration of proper gastrointestinal

function during recovery.*

DPP-4 inhibitors:

work by a glucose dependent mechanism (reducing the

risk of hypoglycemia even in fasting patients)

May be continued if necessary.*

* Sivakumar Sudhakaran and Salim R. Surani, “Guidelines for Perioperative Management of the

Diabetic Patient,” Surgery Research and Practice, vol. 2015

PREOP FASTING

Atleast 6 hours for solid foods.

Patients with gastroparesis, 12 hours may be needed. Such patients are

given H2 receptor blocker(Ranitidine) and prokinetics (metoclopramide).

When fasting exceeds 8-10 hours then insulin-glucose infusion has to be

started to prevent catabolism.

Gastric emptying

(1)- in DM patients

(2)- after Metoclopromide

(3)- normal person

PAC ORDERS Consent

NPO orders

Anxiolytic

Aspiration prophylaxis

Stop long acting insulin night before surgery

Stop OHA 24 to 48 hours before surgery

No insulin on the morning of surgery

Morning sample of Blood sugar and s. electrolytes to be sent

Morning IV fluid according to regimen

Arrange Glucometer, dextro-strips, insulin etc.

Careful transport of the patient

To be taken as the first case

To be contd….

DIABETES MELLITUS &

PERIOPERATIVE MANAGEMENT

SPEAKER DR. TUHIN MISTRY

MODERATORPROF. VANDANA MANGAL

PART - II

ANESTHETIC AGENTS AND DIABETES

Benzodiazepines

secretion of ACTH production of cortisol, when used in high

doses during surgery.*

sympathetic stimulation but, paradoxically, stimulate GH secretion

and result in a decrease in the glycaemic response to surgery.

Effects are minimal when midazolam is given in usual sedative doses,

but may be relevant if the drug is given by continuous i.v. infusion to

patients.

* Desborough JP, Hall GM, Hart GR, Burrin JP. Midazolam modifies pancreatic and anterior

pituitary secretion during upper abdominal surgery. Br J Anaesth 1991; 67: 390–96

High‐dose opiate:

Produce haemodynamic, hormonal and metabolic stability.

effectively block the entire sympathetic nervous system

and the HPA axis, probably by a direct effect on the

hypothalamus and higher centres.*

seen in normal patients and may be of benefit in the

diabetic patient.

* Klingstedt C, Giesecke K, Hamberger B, Jarnberg PO. High and low dose fentanyl

anaesthesia: circulatory and plasma catecholamine responses during cholecystectomy.

Br J Anaesth 1987; 59: 184–8

Etomidate:

Blocks adrenal steroidogenesis and hence cortisol

synthesis by its action on 11 β-hydroxylase and

cholesterol cleavage enzymes. And consequently

decreases the hyperglycemic response to surgery by

approx. 1 mmol/L in non-diabetic subjects.*

The effects on diabetic patients have not been

established.

* Fragen RJ, Shanks CA, Molteni A, Avram MJ. Effects of etomidate on hormonal responses to

surgical stress. Anesthesiology 1984; 61: 652–6

Propofol:

The effect of propofol on insulin secretion is not known.

Diabetic patients show a reduced ability to clear lipids from the

circulation. *

Not relevant when propofol is used for maintenance or as an

induction agent only.

it may have implications for patients receiving propofol for

prolonged sedation in the intensive care unit.

* Wicklmayr M, Rett K, Dietz G, Mehnert H. Comparison of metabolic clearance rates of MCT/LCT and LCT

emulsions in diabetics. J Parenteral Enteral Nutr 1988; 12: 68–71

Ketamine:

Ketamine has a dual effect on blood glucose level.*

Low dose produces hyperglycaemia, mediated via α2-adrenoceptors

high doses produce hypoglycaemia mediated through opioid receptors with

some involvement of β-adrenoceptors that becomes evident only after

blockade of α2-adrenoceptors.

* S. I. Sharif and H. A. Abouazra, “Effect of intravenous ketamine administration on blood glucose levels

in conscious rabbits,” The American Journal of Pharmacology and Toxicology, vol. 4, no. 2, pp. 38–45,

2009.

Inhalationals:

Halothane*, enflurane and isoflurane**, in vitro, inhibit the insulin response

to glucose in a reversible and dose‐dependent manner.

* Gingerich R, Wright PH, Paradise RR. Inhibition by halothane of glucose‐stimulated insulin

secretion in isolated pieces of rat pancreas. Anesthesiology 1974; 40: 449–52.

** Desborough JP, Jones PM, Persaud SJ, Landon MJ, Howell SL. Isoflurane inhibits insulin

secretion in isolated rat pancreatic islets of Langerhans. Br J Anaesth 1993; 71: 873–6.

α2 agonists:

May decrease insulin secretion during peri-operative period

hyperglycemia.

Dexmedetomidine and clonidine decrease ACTH and cortisol

secretion prevent hyperglycemia and maintain haemodynamic

stability.

- Bajwa SJS, Kalra S. Diabeto-anaesthesia: A subspecialty needing endocrine introspection. Indian Journal of

Anaesthesia. 2012;56(6):513-517.

Muscle Relaxants:

Succinyl choline should be avoided in patients with extensive

peripheral neuropathy due to risk of increased potassium

release.

Atracurium and mivacurium are preferred in presence of renal

dysfunction.

Rocuronium may be used in rapid sequence induction.

- Bajwa SJS, Kalra S. Diabeto-anaesthesia: A subspecialty needing endocrine introspection. Indian Journal

of Anaesthesia. 2012;56(6):513-517.

Dexamethasone:

Prevents PONV but may increase blood glucose.

After administration, tight monitoring of blood glucose and correction of

hyperglycaemia is recommended.*

NSAIDS Aggravate gastritis(when on aspirin).Aggravate renal dysfunction.

* Hans P, Vanthuyne A, Dewandre PY et al. Blood glucose concentration profile after 10 mg

dexamethasone in non-diabetic and type 2 diabetic patients undergoing abdominal surgery. Br J Anaesth

2006;97:164-70.

GENERAL ANAESTHESIA & DIABETES

ADVANTAGES

• High dose opiate technique may

be useful to block the entire

sympathetic nervous system

and the hypothalamic pituitary

axis.

• Better control of blood pressure

in patients with autonomic

neuropathy.

DISADVANTAGES

May have difficult airway. (“Stiff-joint

syndrome”)

Full stomach due to gastroparesis.

Controlled ventilation is needed as

patients with autonomic neuropathy

may have impaired ventilatory control.

Aggravated haemodynamic response

to intubation.

It may masks the symptoms of

hypoglycaemia

REGIONAL ANAESTHESIA & DIABETES

ADVANTAGES

Regional anaesthesia blunts the

increases in catecholamines,

cortisol, glucagon, and glucose.

Metabolic effects of anaesthetic

agents avoided

An awake patient – hypoglycaemia

readily detectable.

Decreased chance of Aspiration,

PONV and Thromboembolism.

Rapid return to diet and s/c

insulin/OHA

DISADVANTAGES

If autonomic neuropathy is

present, profound hypotension

may occur.

Infections may be increased

(epidural abscesses are more

common in diabetics)

Medicolegal concern of risk of

nerve injuries and higher risk of

ischaemic injury due to use of

adrenaline with LA

INTRAOPERATIVE GLYCEMIC MANAGEMENT

Surgical stress as well as anaesthesia promotes hyperglycemia

in the diabetic patients

Literature suggests, keep BG levels 150-200 mg/dl(8-11 mmol/L)

during surgery. *

Intraoperative Hyperglycemia(>200 mg/dl) as well as relative Normoglycemia

(<140 mg/dl) both was found to be associated with significant morbidity and

mortality. *

*J. B. Marks, “Perioperative management of diabetes,” American Family Physician, vol. 67, no. 1, pp. 93–100,

2003.

Glucose levels ranging from 140 to 170 mg/dL has the lowest risk of adverse

outcomes.*

For short, minor procedures, preoperative glucose maintenance protocols may

still be employed.

For more major surgeries, variable rate IV insulin infusion has been highlighted

as a more effective method for achieving glycemic control.

*A. E. Duncan, A. Abd-Elsayed, A. Maheshwari, M. Xu, E. Soltesz, and C. G. Koch, “Role of intraoperative

and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery,” Anesthesiology,

vol. 112, no. 4, pp. 860–871, 2010.

1.PATIENTS WHO REQUIRE INSULIN THERAPY

Patients with type 1 diabetes or patients with type 2 diabetes who require day

time insulin injections.

Patients who take both evening and morning doses of insulin should take their

usual dose of evening short-acting insulin but reduce their intermediate or long-

acting dose by 20% the night before surgery.

On the morning of surgery, they should omit their short-acting insulin and reduce

the intermediate- or long-acting dose by 50% (and take this only if the fasting

glucose is >120 mg/dl)

Premixed insulin → reduce their evening dose prior surgery by 20% and hold

insulin completely on the morning of procedure.

Some patients receiving insulin may also take oral AHG.

In patients with type 1 diabetes the insulin infusion rate begins

at roughly 0.5–1 U/hour (mix 50 U short-acting insulin in 50 mL

normal saline; i.e., 1 U = 1 mL), whereas infusion rates are

typically increased in type 2 diabetics to approximately 2-3

U/hour or higher.

A continuous Glucose-Insulin-Potassium (GIK) infusion

technique, which has been supported as an inotropic and

metabolic therapy in several critical disease states.*

*M. A. Puskarich, M. S. Runyon, S. Trzeciak, J. A. Kline, and A. E. Jones, “Effect of glucose-insulin

potassium infusion on mortality in critical care settings: a systematic review and metaanalysis,” Journal of

Clinical Pharmacology, vol. 49, no. 7, pp. 758–767, 2009.

MAJOR SURGERY(MORNING LIST)

Maintain the usual insulin doses and diet the day before and fast frommidnight.

Omit usual morning insulin (and AHG).

Commence an insulin-glucose infusion prior to induction ofanaesthesia.

Measure BGL at least hourly during the intra-operative period.

Continue the insulin-glucose infusion for at least 24 hours post-operatively and until the patient is capable of resuming an adequateoral intake

PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

MINOR SURGERY

MORNING LIST

Delay the usual morning dose of insulin

provided that the procedure is

completed and the patient is ready to

eat by 10:00 am.

The patient can then have a late

breakfast after the usual dose of

insulin is given.

For later procedures, give a reduced

dose of insulin in the morning in

the form of intermediate or long-

acting insulin if possible.

If the BGL remains elevated

(>10mmol/l), an I-G infusion should be

commenced.

AFTERNOON LIST

Pre-operative insulin adjustments

similar to that for major surgery in the

afternoon.

An insulin-glucose infusion may be

necessary if pre-operative insulin

adjustments result in hyperglycemia.

Overnight admission may be

necessary for those with glycemic

instability or who are unable to

resume their usual diet before

discharge.

2. DIABETES CONTROLLED BY DIET

No specific therapy is required.

More frequent BGL monitoring during the peri-operative period isrecommended.

During the procedure, BGLs should be checked hourly.

BGL remains >10 mmol/L (180mg/dl) in the pre- or peri-operative period,an I-G infusion should be commenced and continued until they resumeeating.

If the patient does not become hyperglycemic following surgery, thepatient’s BGL should be monitored every 4–6 hours until they resume theirusual meals.

Patients who are hyperglycemic peri- or post-operatively may requiresupplemental insulin and/or the initiation of specific AHG

*PERIOPERATIVE DIABETES MANAGEMENT GUIDELINES-AUSTRALIAN DIABETES SOCIETY MAY 2012

3. PATIENTS ON OHA(WITHOUT INSULIN)

Omit OHA 24-48 hours before surgery.

Restart it when patients are able to resume normal meals (except metformin

and thiazolidinediones following cardiac surgery).

Commence an I-G infusion if the BGL >180mg/dl, if surgery is

prolonged and or if the patient is usually treated with more than one oral

AHG agent.

Subcutaneous insulin may be required post-operatively


REGIMENS OF INSULIN THERAPY

SLIDING SCALE REGIMEN (S/C)

Glucose in mg/dl Regular Insulin

150-200 2 unit

201-250 4 unit

251-300 6 unit

301-350 8 unit

≥350 10 unit

Limitations:

× Little flexibility

× Variable insulin absorption

× Little rational of their use except minor surgery under local

anesthesia

SLIDING SCALE REGIMEN I.V.

Insulin sliding scale uses 50 U of soluble Insulin diluted up to 50 ml

with normal saline and run at a rate according to the patient’s blood

glucose.

Dextrose and potassium also need to be infused concurrently.

Glucose(mg/dl)Regular Insulin(ml/hr)

<120 Stop infusion

121-150 0.5

151-180 2

181-220 3

221-260 4

261-300 5

>300 6

The amount of

Insulin

administered can

be altered easily

without having to

make up a new

mixture.

DISADVANTAGE

Risk of a failure to

administer

dextrose due to

blockage,

disconnection or

backflow.

ADVANTAGE

• Glucose – Potassium – Insulin infusion

• Alberti and Thomas regimen (1979)

•To commence on the morning of surgery:

500ml 10% glucose

+ 10U Insulin + 10 mmol Kcl

@ 100ml / hr

Blood sugar every 2-3hrs

Blood sugar

<5mmol / L (90mg/dl)

Insulin ↓ to 5U

Blood sugar

>10mmol / L (180-

270mg/dl)

Insulin ↑ to 15U

ALBERTI’S OR GKI REGIMEN

Mechanism :

Lowering circulating levels of free fatty acids and subsequent

myocardial uptake(which are toxic to ischemic myocardium)

Increased myocardial energy production through exogenous

glucose;

Stabilization of intracellular potassium, which may be depleted

during times of myocardial ischemia.

Simple

Safe

Reproducible

Remove the risk

of accidental

Insulin infusion

without

dextrose.

× Need to change the bag if dose of insulin needs to be changed.

× Insulin could be adsorbed in the iv fluid bag and infusion set –could be avoided by flushing solution through infusion set

ADVANTAGE DISADVANTAGE

MODIFIED ALBERTI REGIMEN

500ml of 10%dextrose +

10mmols of KCL +15 U

Insulin @ 100ml/hr

Cont. new GIK

solution at adjusted

conc.

Increase Insulin

by 5 U

Decrease Insulin

by 5 U

Measure

BG every 2

hrs

BG<120mg

/dlBG >200mg/dl

BG 120-200mg

continue @ same

rate

HIRSCH REGIMEN

TIGHT CONTROL REGIMEN

Target Blood Sugar is 80-110 mg/dl.

Indications: Pregnancy, CPB, Neurosurgery.

Advantages: Improve wound Healing,

Prevent wound infection,

Improve neurological outcome.

Night before surgery do preprandial glucose.

Start 5% Dextrose @ 50 ml/hr.

Dissolve 50 U of insulin in 250 ml of NS and start piggy back infusion.

Insulin infusion rate = BG/150 U/hr and

BG/100 U/hr if pt is obese(BMI > 35 kg/m2), on steroid or in sepsis.

RISK HYPOGLYCEMIA

VELLORE REGIMEN

Blood sugar (mg/dL) Treatment

<70 Stop insulin if on insulin. Rapid infusion of 100 mL of

D5W, measure blood glucose after 15 min

71-100 Stop insulin, infuse D5W at 100mL/h

101-150 1U of insulin + 100 mL of D5W/h




>300 1U of insulin for every 50 mg more than 100 mg/dL +

100 ml of normal saline/h

Regular insulin 5 U in 500 mL of 5% dextrose in water solution (D5W) should be started

in the ward at 8 am @ 100 mL/hr until the time of operation.

VARIABLE RATE INTRAVENOUS INSULIN INFUSION(VRIII)

Formerly known as sliding scale insulin.

Make up a 50 ml syringe with 50 units of soluble human insulin in 49.5mls

of 0.9% sodium chloride solution. This makes the concentration of insulin

1 unit per ml.

The substrate solution to be used alongside the VRIII should be selected

from:

• 0.45% saline with 5% glucose and 0.15% KCl, or

• 0.45% saline with 5% glucose and 0.3% KCl

VRIII(CONTD…)

VRIII, has been used for decades to achieve normoglycaemia in

hospitals.

The rate of fluid replacement must be set to deliver the hourly fluid

requirements of the Individual.( volumetric infusion pump).

Delivery of the substrate solution and the VRIII must be via a single

cannula with appropriate one-way and anti-siphon valves .

ARRANGEMENT OF INTRAVENOUS LINE FOR

INFUSION OF REGULAR INSULIN

VRIII(CONTD…)

JBDS guidelines,oct’2014

VRIII(CONTD…)

ADVANTAGES

Accurate delivery of insulin via

syringe driver;

Allowing tight blood glucose

control in the intra-operative

starvation period when used

appropriately;

Flexibility for independent

adjustment of fluid and insulin.

DISADVANTAGES

× Severe hypoglycaemia

× Hyponatraemia

FLUID MANAGEMENT

Aims:

Provide glucose as substrate to prevent proteolysis, lipolysisand ketogenesis.

Maintain blood glucose level between 6-10mmol/L wherepossible (acceptable range 4-12mmol/L).

Optimise intravascular volume status.

Maintain serum electrolytes within the normal ranges.

RECOMMENDATIONS: PATIENTS REQUIRING A VRIII

The substrate solution to be used alongside the variable

rate intravenous insulin infusion should be based on serum

electrolytes, measured daily and selected from:

0.45% saline + 5% glucose + 0.15% KCL;

0.45% saline + 5% glucose + 0.3% KCL.

Very occasionally, the patient may develop hyponatraemia without

overt signs of fluid or salt overload. In these rare circumstances it

is acceptable to prescribe one of the following solutions as the

substrate solution:

0.9% saline + 5% glucose + 0.15% KCl;

0.9% saline + 5% glucose + 0.3% KCl.

RECOMMENDATIONS: PATIENTS NOT REQUIRING A VRIII

AIMS

Provide iv fluid as required

according to individual need until

the patient has recommenced oral

intake.

• Maintain serum electrolytes

within the normal ranges.

• Avoid hyperchloremic metabolic

acidosis.

RECOMMENDATIONS

Glucose-containing solutions

should be avoided unless the

blood glucose is low.

Ringer’s lactate: lactate undergo gluconeogenesis in the liver

and may complicate blood sugar control when given in large

volumes.

Normal saline: infusions in large volume increase risk of

hyperchloremic acidosis.

Ringer’s Acetate: acetate metabolism is unchanged in patients

with DM. rapid infusion of high volume vasodilation,

myocardial depression.

No ideal solution; either solution may be used judiciously.

- R. Zander. Fluid management. Second expanded edition. P. 19-31

THE POST-OPERATIVE PERIOD

Insulin-glucose infusions should be continued until the patients can resume anadequate diet.(or atleast 24 hrs).

I-G infusions should ideally be stopped after breakfast, and a dose ofsubcutaneous insulin (or oral AHG) is given before breakfast.

Hyperglycemia detected post-operatively in patients not previously knownto have diabetes should be managed as if diabetes was present, and thediagnosis of diabetes reconsidered once the patient has recovered from theirsurgery.

Diabetes medication requirements may be increased (or occasionallydecreased) in the post-operative period, and frequent BGL monitoring istherefore essential.

Endocrinologist must be available for the post-operative management ofglycemic instability.


ANAESTHESIA & DM SPECIAL SITUATIONS

DM & EMERGENCY SURGERY

Usually Infected

Usually Uncontrolled

Dehydrated

Metabolic decompensated

Increased resistance to insulin

More Chances of acute Hyperglycemic complication

EMERGENCY SURGERY

Little time for stabilisation of patients ,but if 2-3 hr available

• correction of fluid and electrolyte imbalance .

• Correct hyperglycemia.(start I-G infusion if sugar > 180mg/dl)*

• Treat acidosis.

• Avoid hypoglycemia.

Surgery should not be delayed in an attempt to treat ketoacidosis

completely if the underlying condition will lead to further metabolic

deterioration.

* Management of adults with diabetes undergoing surgery and elective procedures: improving standards-NHS(National institute for health and clinical excellence ) APRIL 2011

If enough time is available – correction of hydration status , electrolytes,

acidosis, blood sugar should be started & should achieve an improving

metabolic trend before starting anaesthesia.

Likelyhood of intra-op hypotension and arrhythmia is more particularly if pt

has pre-op acidosis or hypokalemia.

Intra-op sugar to be monitored more frequently.

Atleast hourly.

LSCS – every 30 min.*

* Management of adults with diabetes undergoing surgery and elective procedures: improving standards-

NHS(National institute for health and clinical excellence ) APRIL 2011

PREGNANCY

Pregnancy is a diabetogenic state. As pregnancy advances insulin resistance

increases.

Hyperglycemia during pregnancy has both maternal and fetal complications &

adverse outcome.

Challenges – Altered maternal physiology & disease associated with

pregnancy.

Maternal hyperglycaemia :

Increases the risk of neonatal jaundice.

The risk of neonatal brain damage, and

Fetal acidosis if the fetus becomes hypoxic

Need tighter control.

More prone for hypoglycemia /hyperglycemia

DKA – usually occurs during 2nd/ 3rd trimester, even develops

with low glucose value of 200mg/dl.

CONTROVERSIES IN DM

GLYCEMIC CONTROL

PATIENT POPULATIONBLOOD GLUCOSE

TARGETRATIONALE

GENERAL

MEDICAL/SURGICAL *

FBS – 90-126mg/dl

RANDOM- <200mg/dl

Decreased mortality , infection

rates, shorter length of stay.

CARDIAC SURGERY * < 150mg/dlDecreased mortality , sternal

wound infection rates.

CRITICALLY ILL # <150mg/dlMortality, morbidity , length of

stay.

ACUTE NEUROLOGICAL

DISORDER $80- 140mg/dl

Lack of data , concensus on

specific target, consensus for

controlling hyperglycemia.

* AMERICAN DIABETIC ASSOCIATION

# SOCIETY OF CRITICAL CARE MEDICINE

$ AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION

CONTD…

Tighter control(80-110mg/dl):

No added advantage, but more risk of hypoglycemia.

Higher glucose – adverse outcome.

In the virtual absence of clinical studies in general surgery, and considering

the basic biological data on the harmful effects of hyperglycaemia, it is

reasonable to recommend that blood glucose should be maintained in the

range 6 to 10 mmol/L, if this can be achieved safely.

A range from 4-12 mmol/L is acceptable. *

* 1.NICE GUIDELINES- APRIL 2011, * 2.AMERICAN DIABETIC ASSOCIATION. * 3.ISPAD-GUIDELINES 2011

METFORMIN

Metformin does not worsen renal function.

For major surgery, metformin should be stopped on the day of surgery andrecommenced(24hr P.O) if serum creatinine level does not deteriorate post-operatively.

Prolonged cessation of metformin will result in deterioration ofglycaemic control and additional anti-hyperglycaemic treatment will berequired.

Metformin & I.V radiocontrast

Creatinine : < 1.4mg/dl safe to continue(need monitoring)

> 1.8mg/dl withdraw 48 hrs.


TAKE HOME MESSAGES

Ensure glycemic control.

Proper preoperative assessment and preparation, check for

DAN.

Avoid prolong fasting, start insulin-glucose Infusion.(keep

BG level <180 mg/dl)

Careful perioperative glucose management can reduce

surgical complications as well as hyper- or hypoglycemic

sequelae which ultimately improves morbidity and

mortality.

Remember: Hypoglycemia is more dangerous than

hyperglycemia.

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